Chapter 100

• This period is characterized by hypermetabolism and sepsis syndrome owing to wound inflammation.
• Adequate nutritional support is critical to attenuate the rate of catabolism.
• Enteral nutrition should begin by 3 days, and 80% of nutritional needs should be met by 7 days.
• Inappropriate use of systemic antibiotics is common during this period because infection is overdiagnosed.
• During this period, wound manipulation and operative procedures must be limited because of wound colonization and hypervascularity.
• Pulmonary complications are the most common cause of mortality during this period; general anesthesia and transport are high-risk periods.
• Anemia is characteristic of this period because of decreased red blood cell production and continued red blood cell losses.
• A close working relationship with the patient is the key to control stress.
• Pain and stress management are major problems often necessitating extensive use of narcotics, sedatives, and antipsychotic drugs.

The interval from day 7 after a burn to wound closure is the most complicated phase of management of a large burn. The systemic effects of burn wound inflammation alter the function of all organ systems and magnify any preexisting organ dysfunction—especially cardiopulmonary dysfunction. There is marked catabolism with loss of body protein, especially from muscle but also from viscera, that can lead to organ dysfunction. The increase in metabolic rate resulting from hormonal response to the inflammatory process leads to a marked increase in O2 consumption and CO2 production. The burn wound is now colonized with bacteria, and wound sepsis is a prominent concern. The hyperdynamic hypermetabolic state makes it increasingly difficult to diagnose wound and lung infection.

Pulmonary problems remain a major cause of morbidity and mortality during this phase.1,2 Respiratory failure and pneumonia surpass burn wound sepsis as causes of mortality. The burn patient is especially prone to pulmonary infection after smoke inhalation. In addition, the hypermetabolic state produces a marked increase in O2 consumption and CO2 production at a time when respiratory function may be seriously impaired by pneumonia, pulmonary edema, or muscle weakness. Burn patients with the combination of inhalation injury and a major body burn have the greatest risk of pneumonia, with a rate approaching 50%. The high incidence is a result of the presence of virulent organisms in the ICU environment and the immunosuppressed state of burn patients. Ciliary action is injured directly by heat and by chemicals in inhaled smoke and often does not regenerate adequately, contributing further to the risk of retention of contaminated secretions and development of pneumonia. Since eradication of an established pneumonia in a burn patient is very difficult, prevention is of primary importance.3

When using antibiotics, it is important to remember that the dosages of most antimicrobials required to obtain adequate levels are much higher in hypermetabolic burn patients.4 If continued intubation is expected for weeks, conversion to a tracheostomy in the first week will greatly assist the clearance of secretions. The tracheostomy should not ...

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